Monday, January 28, 2019

Lung cancer screening: harms, costs, and shared decision making

- Jennifer Middleton, MD, MPH

Controversy continues regarding screening for lung cancer with low dose computed tomography (LDCT). Last fall, Dr. Lin wrote on the blog about overdiagnosis concerns related to LDCT, and now a new study describes the harms and costs that can result from the diagnostic tests that typically follow positive screening results.

 The United States Preventive Services Task Force (USPSTF) gave a B recommendation to screening with LDCT in adults aged 55 to 80 years with at least a 30-pack year tobacco history in 2013, following the National Lung Screening Trial's (NLST) findings that LDCT screening modestly reduced lung cancer mortality. Of note, the American Academy of Family Physicians disagreed with the USPSTF, giving lung cancer screening with LDCT an insufficient evidence rating, both because of its high number needed to treat (312) and its high rate of false positives:

Forty percent of patients screened will have a positive result requiring follow-up, mostly CT scans, although some will require bronchoscopy or thoracotomy. The harms of these follow-up interventions in a setting with a less strict follow-up protocol in the community is not known.

This new study, a retrospective cohort review of over 344,000 patient records, provides information regarding the potential harms of follow-up interventions in a community setting. While the NLST described an estimated complication rate of 8.5-9.8% from invasive diagnostic procedures following a positive LDCT screening result, this larger community study found a much higher complication rate of 22.2-23.8%. Mean complication costs ranged from $6320 for minor complications to $56,845 for major complications.

The Centers for Medicare & Medicaid Services (CMS) mandates shared decision making prior to ordering LDCT for lung cancer screening, but Dr. Lin's post last fall described a 2018 study describing that this shared decision making occurs infrequently and superficially. A 2019 study examining over 8 million Medicare patient records found that only 9% of encounters documented any shared decision making prior to LDCT; interestingly, nearly 40% of patients who did have documented shared decision making opted not to participate in screening.

Shared decision making prior to LDCT is even more imperative given this new data regarding complication rates and costs. Our patients need to understand both LDCT's potential risks and benefits if they are to make a decision about lung cancer screening that aligns with their values.

Tuesday, January 22, 2019

Lessons from recent trials of localized prostate cancer treatments

- Kenny Lin, MD, MPH

From 2012 to 2018, the U.S. Preventive Services Task Force and the American Academy of Family Physicians recommended against screening for prostate cancer, based on evidence that the then-widespread practice produced no net benefit. As a result, fewer family physicians subsequently screened their patients with the PSA test, and fewer men were diagnosed (or overdiagnosed) with localized prostate cancer. However, the USPSTF's recent change to a more permissive approach to PSA-based screening has increased the likelihood that more men will need to make difficult decisions regarding what to do about a prostate cancer diagnosis.

As discussed in a previous AFP Community Blog post, surveyed men with newly diagnosed localized prostate cancer expected to gain an average of 12 years of life expectancy by undergoing surgery or radiation. In fact, two randomized, controlled trials found no gains in prostate cancer-specific or all-cause mortality. After nearly 20 years of follow-up, the U.S. Prostate Cancer Intervention versus Observation Trial (PIVOT) reported in 2017 that radical prostatectomy reduced the likelihood of treatment for asymptomatic, local, or biochemical (PSA) disease progression compared to observation, but caused more urinary incontinence, erectile dysfunction, and limitations in activities of daily living. Similarly, the U.K. Prostate Cancer for Testing and Treatment (ProtecT) trial found that active surveillance was comparable to radiotherapy or prostatectomy, with a slightly greater likelihood of clinical progression and metastatic disease in the active surveillance group.

An older Swedish randomized trial comparing radical prostatectomy to watchful waiting in men with predominantly clinically-detected (rather than PSA-detected) localized prostate cancer found that radical prostatectomy was associated with less than 3 years of life gained after 23 years of follow-up. Altogether, the evidence suggests that curative treatments may be worthwhile for selected men with symptoms, but that there is little or no benefit to looking for prostate cancer in men who feel well.

A 2018 AFP article reviewed the evolving National Comprehensive Cancer Network guidelines for treatment of localized prostate cancer, which recommend incorporating comorbidity-adjusted life expectancy into screening and treatment decisions:

The comorbidity-adjusted life expectancy is particularly important because the number of comorbid diseases is among the most significant predictors of survival after prostate cancer treatment. Prostate cancer is usually slow growing, and the survival benefit of treatment may present only after 10 years. Therefore, patients with low-risk or very low-risk prostate cancer should be treated only if the patient has a comorbidity-adjusted life expectancy of at least 10 years.

Monday, January 14, 2019

AFP Clinical Answers at the point of care

- Jennifer Middleton, MD, MPH

Family physicians have an average of 15-20 clinical questions every day while caring for patients. Identifying trustworthy sources of online or app-based content requires family physicians to identify "whether the reference clearly states how strong the evidence is to support recommendations about patient care." If AFP is one of your trusted sources of answers, you may find our new department, AFP Clinical Answers, of particular interest.

The January 1, 2019 issue of AFP includes the first AFP Clinical Answers article covering nausea in pregnancy, knee osteoarthritis, hormone therapy, and the shingles vaccine. Each content area has a brief paragraph providing key information along with a hyperlink to a more in-depth AFP article. As AFP Editor-in-Chief Dr. Sumi Sexton writes introducing the department, "The goal of this department is to share key clinical questions and their evidence-based answers directly from the journal's content. Our hope is that readers will find these answers useful for patient care and serve as a reminder of the topics we've covered."

If you're interested in further expanding your point of care resources, AFP's Point-of-Care Guides collection provides one-page commentary on the latest evidence base pertinent to many common patient care issues. FPM's (formerly Family Practice Management) SPPACES: App Reviews Department includes reviews for both point-of-care apps for clinicians as well as useful apps for patients. The Agency for Healthcare Research and Quality (AHRQ) also has a "Practical Tools for Primary Care Practice" website with tools and guides on everything from clinical practice guidelines to becoming a high-performing team. 

Don't forget about the "Favorites" feature on the top of the AFP home page, where you can bookmark common resources (from AFP and/or anywhere on the internet) for quick access. You can connect to the Evidence-Based Medicine toolkit from the home page for a refresher on reviewing strength of evidence terms, and you can access the AFP podcast from the home page, too, which frequently features suggestions for additional resources related to content in the print journal.

How are you planning to expand your point of care acumen in 2019?

Tuesday, January 8, 2019

When deprescribing is the best medicine

- Kenny Lin, MD, MPH

Physicians who care for older adults or other patients with multiple chronic conditions understand that deprescribing unnecessary or inappropriate therapies is central to providing high-quality care and improving patient safety. An editorial by Drs. Barbara Farrell and Dee Mangin in the January 1 issue of AFP reviewed the health risks associated with polypharmacy (taking five or more chronic medications) and provided a table of resources for each step of the deprescribing process, including several evidence-based guidelines co-written by the authors. AFP's Practice Guidelines department summarized their guideline on deprescribing antipsychotics for dementia and insomnia last September and reviewed how to taper benzodiazepine receptor agonists for insomnia in adults in the January 1 issue.

A 2018 systematic review in the British Journal of General Practice reviewed data from 27 randomized, controlled trials of deprescribing a range of drug classes in adults aged 50 years or older in primary care settings. In 19 studies, at least half of patients in the intervention groups were able to stop their medications completely, and adverse effects were uncommon. However, the risk of "relapse" (needing to resume the drug after completely discontinuing it) ranged from 2 to 80 percent.

Patient expectations, medical culture, and organizational constraints can present barriers to deprescribing. A qualitative study of New Zealand primary care physicians in the Annals of Family Medicine described deprescribing as "swimming against the tide." Study participants recommended several practice and system-level interventions to support deprescribing that could also be applied to practices in the U.S.:

- Targeted funding for annual medicines review
- Computer alerts to prompt physicians’ memories
- Computer systems to improve information sharing between prescribers
- Improved access to non-pharmaceutical therapies
- Research to build the evidence base in multimorbidity, education and training
- Ready access to expert advice and user-friendly decision support
- Updating guidelines to include advice on when to consider stopping medicines
- Tools and resources to assist in the communication of risk to patients
- Activating patients to become more involved in medicines management and alert to the possibility that less might be better

Along those lines, the AFP editorial also provided a Table of examples of language that family physicians can use to discuss deprescribing with patients and facilitate shared decision-making.

Tuesday, January 1, 2019

Approaches to behavior change that work

- Jennifer Middleton, MD, MPH

It's time for New Year's resolutions, and many of our patients will ask us for help implementing them. The December 15 issue of AFP includes the timely article on "Counseling Patients in Primary Care: Evidence-Based Strategies" which reviews several useful counseling techniques. This article adds to the growing literature of simple methods that can help our patients make healthy changes.

The AFP authors review key tenets of FRAMES, motivational interviewing, BATHE, the stages of change, and the 5A's, providing recommendations about choosing techniques and examples of phrasing to use with patients. All techniques share an emphasis on empathetic patient engagement. The authors also advocate for addressing multiple issues within a visit (such as tobacco use, weight loss, and hazardous alcohol use) and cite data demonstrating that doing so leads to increased change for all of the behaviors addressed.

A 2016 study examined which physician techniques best increased patients' activation scores, a proxy measure for behavior change. More successful physicians used an average of 4 out of the 5 following strategies: "emphasizing patient ownership; partnering with patients; identifying small steps; scheduling frequent follow-up visits to cheer successes, problem solve, or both; and showing caring and concern for patients." Less successful physicians reported instead "telling patients the negative health outcomes they can expect if they do not change their unhealthy behaviors." In this same study, more successful physicians also reported spending more time counseling and had higher interest in behavior change than those physicians whose patients had lower activation scores. 

Additional studies' findings are along similar lines. Spending more time counseling patients correlates with higher rates of behavior change regarding weight loss and tobacco cessation. Patients are more willing to engage in counseling related to behavior change with tobacco and alcohol use when their overall health, and not their undesirable habit, is emphasized. Although leveraging our longitudinal relationships with patients is valuable, it's encouraging to note that just one motivational interviewing session can result in meaningful change, too.

You can read more in the AFP By Topic on Health Maintenance and Counseling. I'm adding this new AFP article to my AFP Favorites page for easy reference. Which of these techniques are you adding to your repertoire for 2019?